1. DRAFT Community Grants Letter of Intent Board priorities for 2014-2015 Grant Cycle: 1) Access to basic healthcare and mental health services 2) Childhood obesity and nutrition 3) Health education to reduce health risk behaviors 4) Senior services to promote independence and quality of life Organization and Program Overview 1.Name of Organization:_____________________________________________________________ 2.Have you received a grant from PHCD in the past?_______________________________________ If yes, please describe your history with PHCD: 3. Program or service this new request will fund: _____________________________________ 4. Is this program/service new or existing? ________________________ 5.Grant amount requested: $____________ Total agency operating budget: $__________________ 6.Total operating budget for the program/services to be funded? $_________________ 7.How will grant funds be used? 6.What is the total number served by the program/service? _________________ 7.What percentage of those are PHCD residents? _________________ 8. How do you track residence status? Date Received (PHCD Use Only) 1

2. DRAFT 9. Briefly describe how the funds will address PHCD health priority (ies): 10. What specific outcomes will be achieved? 11. How will those outcomes be measured? 12. Why is this program important to the health of the people PHCD serves? 13. How do you leverage funds through community collaborations and other grant opportunities? 2 Community Grants Letter of Intent

3. DRAFT 14. When was your organization incorporated?: _______________________________________ 15. Is it a 501(c)(3) organization or government agency?  501(c)(3)  Government agency 16. What are the vision, mission, and values of the organization? 17. Name of CEO and years of service: ________________________________________________ 19. Name of Board President and years of service: _______________________________________ 20. Names of Board Members: 21. Program contact: _____________________ Title:____________________________________ Phone: ____________________ Email: _____________________________________ 3 Community Grants Letter of Intent